Wrong Patient Research Articles

A perspective on wrong level, wrong side, and wrong site spine surgery.

Background: Four of the most common “errors” in spine surgery include: operating on the wrong patient, doing the wrong procedure, performing wrong-level surgery (WLS), and/or performing wrong-sided surgery (WSS). Although preoperative verification protocols (i.e. Universal Protocol, routine Time-Outs, and using the 3 R’s (i.e. right patient, right procedure, right level/side)) have largely limited the first two “errors,” WLS and WSS still occur with an unacceptably high frequency.Methods: In 20 studies, we identified the predominant factors contributing to WLS/WSS; unusual/anatomical anomalies/variants (i.e. sacralized lumbar vertebrae. lumbarized sacral vertebra, Klippel-Feil vertebrae, block vertebrae, butterfly vertebrae, obesity/morbid obesity), inadequate/poor interpretation of X-rays/fluoroscopic intraoperative images, and failure to follow different verification protocols.Results: “Human error” was another major risk factor contributing to the failure to operate at the correct level/side (WLS/WSS). Factors comprising “human error” included; surgeon/staff fatigue, rushing, emergency circumstances, lack of communication, hierarchical behavior in the operating room, and failure to “speak up”.Conclusion: Utilizing the Universal Protocol, routine Time Outs, and the 3 R’s largelly avoid operating on the wrong spine patient, and performing the wrong procedure. However, these guidelines have not yet sufficiently reduced the frequently of WLS and WSS. Greater recognition of the potential pitfalls contributing to WLS/WSS as reviewed in this perspective should better equip spine surgeons to avert/limit such “errors” in the future.

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

Wrong patient selection errors may be tracked by retract-reorder (RAR) events. The aim of this quality improvement study was to assess the impact of reducing the number of concurrently open electronic health records from 4 to 2 on RAR errors generated by a tele-critical care service. The study encompassed 32 months before and 21 months after restriction. Chi-Square test of proportions and T statistical process control chart for rare events were used. There were 156318 orders with 57 RAR errors (36.5/100000 orders) before restriction, and 122587 orders with 34 errors (27.7/100000 orders) after. Rates were not statistically different (P = .20), but analysis was underpowered. When plotted on a T control chart, random variation was detected between RAR errors. We found no significant difference in RAR errors in the tele-critical care setting after open record limitation. Other strategies should be studied to reduce wrong patient selection errors.

Analysis and outcomes of wrong site thyroid surgery

BackgroundIn thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature.Case presentation This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement.ConclusionWSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.

A Workflow for Ensuring DICOM Compatibility During Radiography Device Software Development.

In medical devices, nonconformance with Digital Imaging and Communications in Medicine (DICOM) standard is a serious risk. DICOM nonconformance radiology devices could cause undetected image loss, increasing examination time, and costs in health centers and could even result in the wrong patient treatment. However, there is a rich literature on medical standards that identify the best practices for producing safe and effective medical software. However, these standards do not expressly provide tools to deal with all the relevant DICOM compatibility issues in a specific case. This study aims to introduce a systematic software development workflow that complies with medical standards and ensures DICOM conformance of a new or upgraded radiology software project. In this approach, DICOM conformance gets the highest priority, and the whole software project is organized around it. Software requirement analysis, risk evaluation, and test management tasks are arranged systematically to make the final device DICOM conformant. This conceptual framework was developed during the R&D work towards a novel radiography device, and it could be employed as a roadmap in other medical imaging software projects. The proposed methodology controls the DICOM compatibility risk of the final software, and its systematic evaluation complied with medical standards.

Patterns of Medication Errors Involving Older Adults Reported to the French Medication Error Guichet.

The aims of the study were to describe medication errors (MEs) involving older adults reported to the French Medication Error Guichet and to compare them with MEs in younger adults, in each of the hospital and community settings. Retrospective secondary data analysis of MEs reported throughout 2013 to 2017 was performed. Descriptive and multivariate analyses were performed to compare actual and potential ME reports between older adults (aged ≥60 y) and younger adults (aged ≥18, <60 y). We analyzed 4979 reports. In older adults, both in hospital (n = 1329) and community (n = 1264) settings, antithrombotic agents were frequently reported in MEs and were significantly more likely to be associated with reported MEs in older adults compared with younger adults. In hospital setting, antibacterials for systemic use (adjusted odds ratio [aOR] = 1.87, 95% confidence interval [CI] = 1.19-2.93) and antineoplastic agents (aOR = 2.22, 95% CI = 1.34-3.69), whereas in community setting, psycholeptics (aOR = 1.43, 95% CI = 1.04-1.98) and drugs used in diabetes (aOR = 6.01, 95% CI = 3.21-11.2) were more likely to be associated with reported MEs in older adults. In both settings, wrong dose and wrong drug were the most frequently reported error types in older adults; however, wrong technique error type (aOR = 2.06, 95% CI = 1.30-3.28) in hospital setting and wrong patient (aOR = 2.17, 95% CI = 1.30-3.60) in community setting were more likely to be associated with reported MEs in older adults. We identified specific ME patterns for older adults, including antithrombotic agents in both settings; antibacterials for systemic use, antineoplastic agents, and wrong technique in hospital setting; and psycholeptics, drugs used in diabetes, and wrong patient in community setting. These findings inform future studies investigating population-specific medication safety strategies.

Rates of Serious Surgical Errors in California and Plans to Prevent Recurrence

Despite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised. To examine surgical never events occurring in hospitals in California and summarize recommendations to prevent future events. This cross-sectional study identified 386 CDPH hospital administrative penalty reports, of which 142 were ascribable to never events occurring during surgery. These never events were identified and summarized from January 1, 2007, to December 31, 2017. A directed qualitative approach was used to analyze CDPH-mandated corrective steps to reduce future errors in this multicenter study of all accredited hospitals in California. Inclusion of surgical never event records was based on definitions established by the US Department of Health and Human Services National Quality Forum. Data analysis was performed from January 1, 2019, to November 30, 2020. Never events include death or disability of an American Society of Anesthesiologists class I patient, wrong site or wrong surgery, retained foreign objects, burns, equipment failure leading to intraoperative injury, nonapproved experimental procedures, insufficient surgeon presence or privileges, or fall from the operating room table. Incident rates, consequences, and improvement plans to prevent additional never events were outcomes of interest. A total of 142 never events were reported to the CDPH (1 per 200 000 operations). Annual surgical volume for hospitals with events was 9203 vs 3251 cases for hospitals without events (P < .001). A total of 94 of 142 events (66.2%) were retained foreign objects ranging from Kocher clamps to drain sponges. Wrong site or patient surgery accounted for 22 events (15.5%), surgical burns for 11 (7.7%), and other for 15 (10.6%). Other included insufficient surgeon presence, equipment failure, or falls in the operating room. Improvement plans included 18 unique categories of recommendations from regulators, many focusing on proper use of checklists. Regulators mandated a mean (SD) of 13 (7) corrective actions in the improvement plans. Policy adherence monitoring (119 [90.2%]), revision of existing policy (84 [63.6%]), and education regarding policy (83 [62.9%]) were common action items, whereas disciplinary action toward staff was rare (11 [8.3%]). Surgical never events are a rare issue in California. Numerous strategies have evolved to reduce errors, many involving the thorough and proper use of intraoperative checklists.

Is There An Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review.

Is There An Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review.

RETRACTED: Remission of Subacute Psychosis in a COVID-19 Patient With an Antineuronal Autoantibody After Treatment With Intravenous Immunoglobulin

Retraction notice to: “Remission of Subacute Psychosis in a COVID-19 Patient With an Antineuronal Autoantibody After Treatment With Intravenous Immunoglobulin” by Lindsay S. McAlpine, Brooke Lifland, Joseph R. Check, Gustavo A. Angarita, Thomas T. Ngo, Samuel J. Pleasure, Michael R. Wilson, Serena S. Spudich, Shelli F. Farhadian, and Christopher M. Bartley (Biol Psychiatry 2021; 90:e23-e26); https://doi.org/10.1016/j.biopsych.2021.03.033. This article has been retracted at the request of corresponding author Christopher Bartley, with agreement from all authors and with approval from Biological Psychiatry Editor John H. Krystal, M.D. See Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). After this article was published, the authors determined that two cerebrospinal fluid (CSF) samples were inadvertently confused, resulting in publication of the wrong COVID-19 patient’s immunostaining data. The authors determined that the two CSF samples came from COVID-19 patients with sequential case identifiers (i.e., one identifier ended in a “5” and the other in a “6”). To determine whether the published immunostaining results were produced by CSF from another COVID-19 patient, the authors reperformed the mouse brain immunostaining experiments using additional aliquots of stored CSF from the two research participants in question, as well as with the remaining CSF that had been used in the publication. After repeating the immunostaining with these CSF samples, two blinded raters were able to state unequivocally that the CSF samples from the two COVID-19 patients had been confused. Therefore, while the clinical features of the case report are accurate and unaffected, the research data belong to another COVID-19 research participant, not the one described in the published case report. The authors voluntarily informed the Journal of this honest error upon its discovery. All authors agree to retract this paper and sincerely apologize for having allowed the incorrect images to be published with this case report. To avoid misinterpretation of the research findings, both the editors and authors concur that the only proper course of action was to retract this version of the paper. However, this COVID-19 psychosis case remains of clinical interest because of the patient’s clear response to immunotherapy. Therefore, the authors are revising the paper, which the Journal will consider further for publication.

Sleep Quality Among Healthcare Workers During the COVID-19 Pandemic and Its Impact on Medical Errors: Kuwait Experience.

Millions of people suffer from sleep disturbances. In addition, the coronavirus disease 2019 (COVID-19) pandemic created several new challenges-particularly for frontline healthcare workers (HCWs). This study assessed the sleep quality (SQ) among HCWs. A cross-sectional study was conducted using an English-language online survey. The participants were invited via a web link sent using social network platforms. It included sociodemographic- and profession-related characteristics. COVID-19-associated risks were assessed (e.g., being on the front line, doing swabs, satisfaction about protective equipment, and management protocols). Assessment of SQ was done using the Pittsburgh Sleep Quality Index (PSQI) and various medical errors were recorded. A total of 217 HCWs completed the survey with mean (±standard deviation) age of 35.8 (±7.3) years; 56.2% were male, 18.43% had comorbidities, and 61.75% experienced sleep difficulties before the COVID-19 crisis. This work reports a 78.8% prevalence of poor SQ, with the mean (standard deviation) global PSQI score of 9.36 (±4.4). HCWs with poor sleep experienced more positive comorbid profile (23.64% versus 6.52%, p=0.01). Working on the front lines of COVID-19 was associated with poor sleep (69.59% versus 47.83%, p=0.006). Among the participants, 77.42% performed medical errors, particularly not checking for drug allergies (17.97%), dispensing medication with incomplete instructions (20.74%), providing incorrect doses or overdosing (14.75%), incorrectly explaining the use of medication (9.22%), and prescribing a drug to the wrong patient (10.14%). This nationwide survey reported high prevalence of poor SQ among HCWs during the COVID-19 pandemic. Being an HCW on the front lines of COVID-19 and doing swabs with a positive comorbidity was associated with poor sleep.

Effect of barcode technology on medication preparation safety: a quasi-experimental study.

Medication errors are a common problem in hospitals and a major driver of adverse patient outcomes. Barcode verification technology is a promising strategy to help ensure safe medication preparation practices. The objectives of this study were (i) to assess the effects of a barcode-assisted medication preparation and administration system regarding the rate of medication preparation errors and (ii) to compare the time spent on medication preparation tasks by medical staff. A quasi-experimental study with a pre-post design was conducted, from August 2017 to July 2018, in two mixed medical/surgical units of a tertiary teaching hospital. The primary aim was to assess the effects of a barcode-based electronically assisted medication preparation and administration system linked to the hospital's electronic medication administration record regarding the rate of medication preparation errors and time-based staff performance. Data were collected using direct observation. Adjusted and unadjusted logistic models were used for error frequencies and linear regression models for time performance. 5932 instances of medication selection and dosing during 79 medication preparation procedures were observed. The overall medication preparation error incidence decreased from 9.9% at baseline to 4.5% at post-intervention, corresponding to a relative risk reduction of 54.5% (P < 0.001). However, the adjusted effect by registered nurses (RNs) and nurses' work experience of total medication preparation errors showed only borderline significance (odds ratio [OR] 0.64, P = 0.051). For adjusted error-specific analyses, significant error reductions were found in wrong medication errors (OR 0.38, P < 0.010) and wrong dosage errors (OR 0.12, P = 0.004). Wrong patient, wrong form and ambiguous dispenser errors did not occur at post-intervention. Errors of omission (OR 1.53, P = 0.17), additional doses (OR 0.63, P = 0.64) and wrong dispenser boxes (OR 0.51, P = 0.11) did not change significantly. The time necessary to prepare medications for a 24-h period also decreased significantly-from 30.2 min to 17.2 min (beta = -6.5, P = 0.047), while mean preparation time per individual medication dose fell from 24.3 s to 15.1 s (beta = -5.0, P = 0.002). Use of the new barcode technology significantly reduced the rate of some medication preparation errors in our sample. Moreover, the time necessary for medication preparation, both per 24-h period and per single-medication dose, was significantly reduced.

Nurses’ Perception about Medication Errors Types, Causes and Barriers to Report it

Background: Since there is a continuous rise in the number of patients requiring quantity of prescribedmedications and medical care, there is always an increasing requirement for a complete system that cancarefully evaluate all the medication errors that may occur.Objective: Determine types, causes, and barriers of medication errors reportSetting: The current study was conducted in Imam Sadiq Hospital - Babel City during 2019 yearSubjects: The study comprised of 100 nurses with at least two years of clinical experienceTools: The Medication Administration Errors (MAEs) method was used to gather the data by reportingruestionnaire that was formulated by Wakefield et al.(1996) and revised by the researchers. The questionnairehas 65 questions; 15 items are related to the reasons of medication errors occurrence, 7 items concerningthe reasons of not reporting medication errors and 5 items related to the percentage of each medicationerror type reported on units which classified into 9 items for non- intravenous and 11 items for intravenousmedication administration errors.Results: most of nurses reported no mistakes related to wrong route, wrong dose, wrong method;Whilewrong time, allergic reaction and infusion rate mistakes were more repetitive errors accordingto their perception. Fears about punishmentand from patient relatives was most common barriers to reportmedicationerrors.Conclusion: Medication errors is highly priority health system problem; more than half of nurses reportedno mistakes related to wrong dose, wrong method, and wrong patient, most of them indicated that no clearlydefinition of medication error was identified, unclear reporting system wasexisted.Recommendations Assessment and surveillance system should be followed to minimize medication errorspotentiality. Nurses have to always remember that they are responsible and accountable to the results of theirdecisions andactions whatever they are.

P41.06 As Seen from the Rearview Mirror: A Retrospective Analysis of Lung Cancer Screening in Patients with Lung Cancer

Lung cancer (LC) is the leading cause of cancer-related deaths worldwide. The U.S. Preventive Services Task Force (USPSTF) and National Comprehensive Cancer Network (NCCN) recommend LC screening with low dose CT (LDCT) in high-risk individuals who meet criteria, which primarily focus on age and smoking history. Despite this, screening rates remain low. We conducted a retrospective analysis of patients with LC to evaluate the screening practices and rates for screening prior to their LC diagnosis. Patients diagnosed with LC between 2016 and 2019 were included in the analysis. Charts were reviewed for demographics, detailed smoking history, as well as histology and stage of LC. Associations between categorical factors and screening and were examined using the chi-square test. Associations between continuous and ordinal factors and screening and were examined using the Mann-Whitney test. Of the 530 charts reviewed, 64.3% and 43.2% met NCCN and USPSTF criteria for screening, however, only 10.9% and 12.9%, respectively, were referred for screening. A total of 4% and 4.9% of the subjects who did not meet NCCN nor USPSTF criteria were referred for screening [Table 1]. Of the 30 eligible patients who underwent screening, only 36.7% had LDCT, while 20% had chest X-ray and 43.3% had other types of CT scans. Eligible patients that met NCCN and/or USPSTF criteria and underwent screening were diagnosed at earlier stages [graph 1].Table 1Screening tendencies for eligible and ineligible patientsReferred for screeningMet NCCN criteriaDid not meet NCCN criteriaMet USPSTF criteriaDid not meet USPSTF criteriaYes30 (10.9%)6 (4%)24 (12.9%)12 (4.9%)No246 (89.1%)145 (96%)162 (87.1%)233 (95.1%) Open table in a new tab Our study showed that despite established guidelines for LC screening and insurance coverage, a vast majority of screening-eligible LC patients have never had LDCT. Lack of patient referral and wrong patient selection for screening suggests that physicians are not comfortable or entirely aware of screening guidelines. In patients that were eligible for screening, there was an improvement in earlier staging even with suboptimal screening.

An evaluation of the formalised AcciMap approach for accident analysis in healthcare

This paper presents a field workshop organised by the Healthcare Improvement Scotland (HIS) focusing on the evaluation of the formalised AcciMap approach by patient safety practitioners of the National Health Service (NHS). Participants who were experienced in incident analysis relating to patient safety and risk management across different NHS boards but had no prior knowledge using the AcciMap approach were recruited for a case study analysis (Wrong Patient) (Chassin and Becher in Ann Intern Med 136:826–833, 2002). They were subsequently divided into three teams after introduction and training, where each team performed an independent case analysis. AcciMap outcomes produced indicated both similar and varying contributing factors identified by each team. This was also reflected in their formulation of safety recommendations. Their findings were then compared with each other (reliability) and with external review (validity). Based on results obtained from the survey instrument distributed after the exercise and focus discussions, the AcciMap approach was generally perceived as intuitive and a potentially relevant toolkit for incident investigations. However, questions were raised particularly regarding the usability (ease of use) in conducting analyses compared RCA techniques.

Redo stapled haemorrhoidopexy: our experience at max hospital, Gurugram

Stapled haemorrhoidopexy like any other surgical procedure can also fail due to error by surgeons or machine, the stapler. Experience of the surgeon plays the most important role in avoiding recurrence of haemorrhoid after stapled haemorrhoidopexy. A description of operative technique and patient’s demographics are presented. Ten cases of recurrence of haemorrhoid after stapled haemorrhoidopexy done elsewhere were managed by redo haemorrhoidopexy between 1st June 2011-1st June 2020 at Max hospital, Gurugram, Haryana. All cases were successfully operated though the reason of recurrence was different in these cases. Haemorrhoids or piles are common surgical problem a surgeon faces. The first known mention of this disease is from a 1700 BC Egyptian Papyrus. Stapled haemorrhoidopexy is a new and successful technique to treat haemorrhoids, was developed by Dr. Antonio Longo, Italian surgeon, in 1998.Stapled haemorrhoidopexy avoids formation of wound in the operative area, has the advantage of significantly reducing the post-operative pain. Inadequate knowledge and experience, over confidence, wrong patient selection, improper fixation of circular anal dilator, purse string at wrong site, are common causes of recurrence. We managed the recurrence with taking care of causative factors while doing redo-stapled haemorrhoidopexy successfully in all cases. No case of recurrence of haemorrhoids after stapled haemorrhoidopexy was considered for conventional haemorrhoidectomy. All cases were done with redo-haemorrhoidopexy.

Errors and Near-miss Errors Encountered by Nursing Students in Clinical Settings in Governmental Universities, Khartoum State (2018)

Background: Identifying and analyzing the occurrence and sort of student clinical errors which will allow for early detection of problems and offer chance for system evaluation and improvement. This study intended to explain the types of errors along with near-miss errors encountered by nursing students in clinical settings. Methods: This descriptive cross-sectional study was conducted at five recognized governmental universities in Khartoum State and included 470 nursing students in their fourth year (2017–2018)who met the selection criteria of the study. A full-converge sampling method was used and data were first collected by the researcher using published self-administered survey and then analyzed.&#x0D; Results: Initially, the study included 519 nursing students but only 470 of them responded(at a rate of 90.5%).The responses showed that while one-third of them, that is, 162(34.5%) students, had never encountered an error, 99(21.1%), 79 (16.8%), 71 (15.1%), 46(9.8%), and 13(2.8%) of them encountered errors with respect to needle stick, medical administration, omission of treatment, and wrong treatment, respectively. Regarding the near-miss errors encountered by the respondents, almost half, that is, 202(43%)of them had never encountered a near-miss errors, while 112(23.8%), 106(22.6%), 18(3.8%),17(3.6%), and 15(3.2%) of them encountered near-miss errors with respect to medication administration, omission of treatment, wrong patient, providing wrong treatment and others such as improper bedrail used, did not follow sterile precautions respectively. Conclusion: This study concluded that errors and near-miss errors exist and that awareness on clinical errors and near-misses need to be raised and strategies be developed for error management.&#x0D; Keywords: errors, near-miss errors, nursing students, clinical setting, nursing errors

“This is the wrong patient’s blood!”: Evaluating a Near‐Miss Wrong Transfusion Event

“This is the wrong patient’s blood!”: Evaluating a Near‐Miss Wrong Transfusion Event

Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

A New Visual Cryptography-Based QR Code System for Medication Administration

In health care, medication errors can result in serious health risks to patients, and hospitals require a secure medication administration system to prevent such errors. This paper therefore proposes a secure medication administration method based on threshold sharing technology. When a patient visits a doctor and the doctor prescribes n medications, a photo and the personal information of the patient are encoded into n QR code transparencies that can be decoded by common QR code scanners available for smartphones. The prescription and n QR code transparencies are then stored in a hospital’s medication administration system. When the patient receives their medicine, they can scan these n QR code transparencies using a smartphone to ensure that they have all the medicines prescribed by the doctor; this function is accessible even if the patient’s phone does not have Internet access. The main purpose of the proposed system is to prevent hospitals from giving medicine to the wrong patient, or giving less than the prescribed dosage of medicine to the patient. The focus is not on the internal medicine packaging process in hospitals but on reducing the probability of counter staff giving medicine to the wrong patient. This function is of considerable importance to non-English-speaking people who are not used to reading medicine names in English.

Trend in ABO-incompatible RBC transfusion-related fatalities reported to the FDA, 2000-2019.

ABO-incompatible red blood cell (RBC) transfusions and acute hemolytic reactions occur infrequently, yet resultant fatalities are reported to the US Food and Drug Administration (FDA) every year. We describe a 20-year retrospective study of reported mistransfusion cases to identify temporal trends, common causes, and corrective actions taken to prevent recurrence. ABO-incompatible RBC transfusion-related fatalities reported to the FDA in 2000-2019 were reviewed for patient demographics, primary attributed cause, contributing factors, and corrective actions. Eighty reported deaths after ABO-incompatible RBC transfusion occurred in the 20-year period. A decrease in the number of cases after 2008 was sustained through 2019 (mean 6 cases/y, 2000-2009 vs 2 cases/y, 2010-2019). The estimated rate of reported mistransfusion fatalities was 1 per 2 million RBC units transfused in 2000-2009 and 1 per 7.14 million RBC units in 2010-2019 (P < .0001). Administration errors (wrong patient or wrong unit transfused) and sample collection errors (wrong blood in tube [WBIT]) significantly decreased over time but remained the most common causes. In all WBIT cases, verification of patients' ABO type with a second sample or historical type was not performed before transfusion; 16 of 19 (84%) institutions that reported corrective actions subsequently instituted this requirement. In the other categories, 22 of 58 (38%) facilities reported plans for technological process improvements, such as electronic patient identification. The rate of reported fatalities from ABO-incompatible RBC transfusion has significantly decreased in the past decade. Still, about two cases are reported each year, highlighting gaps in best practices and areas for improvement.

Evaluation of Telepharmacy Services in Light of COVID-19.

Background: Telepharmacy services are expected to have an important role in increasing access of patients to pharmaceutical care and reducing potential dispensing errors in community pharmacies. Objective: To assess the predictors for effective telepharmacy services on increasing access of patients to care and reducing dispensing errors in community pharmacies. Method: This is a prospective study carried out for 4 months in 52 community pharmacies across the United Arab Emirates (UAE) using disguised direct observation. Multivariable logistic regression was used as a tool to predict factors associated with effective telepharmacy services in improving dispensing safety and increasing access of patients to pharmaceutical care. Data were entered and analyzed using the Statistical Package for Social Science (SPSS) software version 26. Results: Pharmacist recommendations related to COVID-19 at pharmacies with telepharmacy (n = 63,714) versus those without remote services (n = 15,539) were significantly more likely to be (1) contact the nearest testing center (adjusted odds ratio [AOR] = 7.93), (2) maintain home quarantine (AOR = 5.64), and (3) take paracetamol for fever (AOR = 3.53), all were significant results (p < 0.05). Rates of medication dispensing errors (MDEs) and its subcategories, prescription-related errors, and pharmacist counseling errors across pharmacies with telepharmacy versus those without remote services were (15.81% vs. 19.43%, p < 0.05), (5.38% vs. 10.08%, p < 0.05), and (10.42% vs. 9.35%, p > 0.05), respectively. However, pharmacies with telepharmacy were more likely to include wrong patient errors (AOR = 5.38, p < 0.05). Conclusions: Telepharmacy can be used as a tool to reduce the burden on the health care system and improve drug dispensing safety in community pharmacies.